Improving Patient Outcomes and Reducing Expenditures through increased compliance with Standard Treatment Guidelines (STGs) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in Ilembe District, KZN
Vani Naidoo Manager :Pharmaceutical Services ILembe District Office Sushila Reddy Stanger Hospital Pharmacy Manager Vimal Singh Montebello Hospital Pharmacy Manager
HST Conference 5 May 2016
Outline of Presentation Background
Current Situation
Policies and Legislation
Stakeholder Analysis
Monitoring and Evaluation plan
Root Cause Analysis
Methodology
Findings/Results
Cost Considerations
Impact of project on work environment
Lessons learnt
Way forward
Conclusion
References
Acknowledgements
Background
POPULATION
662 413
Sundumbili CHC
Stanger Regional Hospital
Montebello District Hospital
No of Regional Hospitals 1
No of District Hospitals 3
No of Community Health Centre's
2
No of PHC Clinics 31
Background cont…
• NSAIDS widely used for management of pain &
inflammation
• Rational prescribing imperative
• Extensive range of side effects ( gastric, renal,
cardiovascular)
• Different levels of care provided at selected sites
• Common problem: non-adherence to STG /Essential Medicines List (EML)
• KZN and facility ABC analyses 2012-2013: Indomethacin suppositories was an A category item
Background cont…
Facility Annual Usage (units)
2012/2013
Annual Expenditure
in Rands
ABC Category
Stanger 15 624 R 312 480 A
Montebello 3 880 R 77 600 A
Sundumbili 6 552 R 131 040 A
PPSD 707 613 R 13 275 845 A
Background cont…
Rational Prescribing
STG audits for Compliance
Improving Patient Outcomes
Current Situation
Cu
rre
nt
Situ
atio
n
Ass
ess
me
nt Knowledge of STG/EML
Prescription compliance with STG/EML on NSAIDS
Baseline Audit 2013– Knowledge of STG/EML
• Pharmacy and Therapeutics Committee (PTC) meetings were not held or did not address relevant STG issues
• Doctors and pharmacists did not have a clear understanding of role of EML and National Drug Policy (NDP)
Pharmacy Department Quality Evaluation Survey on EML and STGs Instructions to respondents: Please place a cross in the appropriate box for each of the questions 1. Have you heard of EML and STG? Yes No 2. What do EML and STG stand for? EML: ______________________________________________________ STG: ______________________________________________________ 3. Have you had formal training on EML and STG? (Formal = trained in undergraduate curriculum or attended a workshop training programme) Yes No 4. How would you rate your current knowledge of EML and STG on a scale of 1 to 5? 1= poor I do not understand EML/STG and do not use it 2= marginal I have a vague understanding of it and use it sometimes 3= satisfactory I have a fair understanding and use it sometimes 4= good I have a good knowledge on EML/STG and use it often 5= excellent I have an excellent knowledge base about EML/STG and use it. 5. Would you like to have regular training on EML/STG?
Yes No If yes, what aspects of EML/ STG training will you like to receive? _________________________________________________________ Thank you for your participation.
Baseline Assessment Tool – Doctors and Pharmacists
Doctors and pharmacists self rating of STG /EML knowledge and training audit - August 2013
67% 70%
20%
85%
100%
10%
98% 90% 90%
0102030405060708090
100
Stanger[n=55] Montebello [n=10] Sundumbili [n=10]
Per
cen
tage
of
do
cto
rs a
nd
ph
arm
acis
ts
% Less than Good Knowledge
% No Formal training
% Requested Training
Name of Institution
Baseline Audit : Prescription compliance with STG/EML on NSAIDS
• No institutional policy regarding NSAID use
• KZN PTC 2010 NSAID policy was not yet aligned with 2012 STG/EML
Baseline Results of Prescription Audit
Stanger Montebello Sundumbili
Prescriptions
Number of Acute Prescriptions 100 50 27
Number of Chronic Prescriptions 100 50 73
Total Number of Prescriptions 200 100 100
% Prescriptions with Multiple NSAIDs 1.5 0 0
Compliance % Compliance with Prescriber Level
98 95 100
% Compliance with STG/EML/KZN PTC/Institution Policy
57 60 37
Impact of Current Situation Poor knowledge of current policy and guidelines
Non-compliance with STG/EML
Irrational prescribing
Increased risk of side effects
Increased risk of co-morbidities
Increased burden of disease
Erratic stock quantification
Inappropriate use of medicines
budget
Inefficient Service Delivery
Challenge
How can we improve the percentage compliance with STG/EML for NSAIDS, in adult prescriptions at the three
facilities identified, given that
There are poorly functioning institutional PTCs with regard to the National Drug Policy
and Standard Treatment Guidelines
There is poor compliance of prescriptions with STG/EML
National Drug Policy of South Africa (1996)
Rational Drug Prescribing
Cost-effective Drug usage
Public Finance Management Act 1 (1999)
Effective budget utilisation
STG/EML Hospital Level (2006, 2012)
Reference for previous and current guidelines
KZN PTC Policy on NSAIDS (2010)
Current provincial guidelines
Relevant Policies & Legislation
Stakeholder Analysis
Rational use of
NSAIDs
Medical Officers
Dentists
Pharmacists
Pharmacy Manager
Medical Manager
PTC Members
Monitoring and Evaluation Plan
Indicator Definition Data Source
Data Collection method
Frequency of data collection
1. Percentage prescriptions compliant with STG for NSAID’s
No of doctor’s prescriptions compliant with STG(NSAIDS)/ Total prescriptions for NSAIDS audited NSAID, EML, STG, compliance= appropriate prescribing as per STG/EML : dose, frequency, duration, prescriber level
Patient files and prescriptions
Record Review
Baseline: daily for 2 weeks in August 2013 and January 2014
2. No. of health care workers (HCW) trained on STG/EML
HCW = doctors and pharmacists at hospitals and CHC; Trained: attended an in-house workshop on STG/
Tool - Individual Register
Presentation October 2013
MISSION
To enable accessible, co-ordinated, integrated pharmaceutical services based on principles of rational drug use to
provide cost-effective quality care to all stakeholders in Ilembe
VISION
Quality pharmaceutical services for a happy healthy Ilembe
Measurable Result
To improve % of prescriptions for adult patients compliant with EML/STG to NSAIDS by 20% in 1 Regional Hospital [Stanger] 1 District Hospital [Montebello] and 1 CHC [Sundumbili ] by Jan
2014
Current Situation
There is 57%, 60% and 37% prescription compliance to STG/ EML on NSAIDS at Stanger, Montebello and Sundumbili respectively
Obstacles and Root Causes
• Provincial / Institutional Policy on use of NSAIDS not clear and updated as per hospital EML 2012 .
• Institutional PTCs not optimally functional • EML not a standing item on the agenda • Lack of in-service training and orientation on STG • Poor translation of KZN PTC decisions into
policy/practice
Challenge
How can we improve percentage prescriptions compliant with STG/EML for NSAIDS by 20% ,considering there is a poor functioning of institutional PTC with regard to NDP, STG and EML and health care workers’ orientation
Priority Actions
Train and orientate all prescribers and pharmacists on compliance with STGs
Strengthen PTC with NDP and EML Focus
Strengthen communication between provincial and district/institutional PTCs
Root Cause Analysis
POLICIES
PEOPLE
PROCESSES AND PROCEDURES
Policies • Provincial / Institutional PTC Policy
on use of NSAIDS not clear and updated as per Hospital EML 2012
Processes and procedures • Institutional PTCs not optimally functional • EML not a standing item on institutional PTC
agenda • Lack of training and orientation on STGs/EML • Poor translation of KZN PTC decisions into
policy/practice
People • Lack of knowledge • Resistance to comply
Poor compliance with NSAIDS prescribing, in accordance with STG/EML, resulting in irrational medicine usage and poor patient management.
INTERVENTIONS
Action Time Period
1. Strengthened communication with prescribers and pharmacists by including STG on monthly PTC agendas
August 2013
2. Aligned institutional NSAID Policy with that of KZN PTC Policy at Stanger Hospital
August 2013
3. Conducted training on National Drug Policy, STGs/ EML on NSAIDS
October 2013
4. Monitored prescriptions and provided additional support to prescribers
November-December 2013
5. Re-audited prescriptions for compliance January 2014
FINDINGS/ RESULTS
Results : No of Doctors & Pharmacists trained on STG/EML/NDP/NSAIDs
FACILITY DOCTORS TRAINED PHARMACISTS TRAINED
STANGER HOSPITAL 45 11
MONTEBELLO HOSPITAL 8 2
SUNDUMBILI CHC 8 4
TOTAL 61 17
% Compliance with STG/EML for NSAIDS
57 60
37
94
68 67
0
20
40
60
80
100
Stanger(n=200) Montebello(n=100) Sundumbili(n=100)
Pe
rce
nta
ge P
resc
rip
tio
ns
com
plia
nt
wit
h
STG
/EM
L
Facility Baseline Compliance to STG/EML 2013
Post-intervention Compliance to STG/EML 2014
Results cont…
• More requests received from doctors for copies of EML/ STG.
• More discussion on other STG by doctors and pharmacists.
• Increased referencing of EML by both doctors and pharmacists.
Example of Potential Cost Savings (2013)
Treatment Arm Prescription Cost/patient per month
Annualised Cost per 1000 patients
Non-compliant NSAID usage for treatment of Osteoarthritis
Indomethacin 100mg suppository 1 nocte x 1/12 (30)
R60 per patient/month (R20/10 supps)
R720 000/1000 patients per annum
Compliant NSAID usage for treatment of Osteoarthritis
Ibuprofen 400mg tds x 1/12 (84)
R7.71 per patient/month (R7.71/ 84 tabs)
R92 520/1000 patients per annum
Difference
R627 480/1000 patients per annum
Discussion
• All facilities showed improvement in compliance of prescriptions with STG for NSAIDs
• Sundumbili CHC and Stanger Hospital achieved greater than the targeted 20% improvement in compliance
• Stanger Hospital attained the highest improvement (37%) due to a functional PTC, improved communication between prescribers and pharmacists and consistent monitoring and intervention by pharmacists.
Discussion
• Montebello achieved an 8% improvement in compliance:
• Although all stakeholders were trained , monitoring and intervention by pharmacists was poor
• Peer review showed that Stanger and Sundumbili had greater success than Montebello due to active intervention by pharmacists, post-training
• The work climate in this facility still needed to be analysed further
Impact of project on work environment
• Attitudes and Relationships across teams
• The Pharmacist in Multi Disciplinary Team was recognized as integral member in promoting rational drug use
Impact of project on work environment cont……
• Less resistance to change due to increased awareness of current policy and legislation.
• As understanding of NDP and EML became clearer there was commitment and improved communication.
Lessons learnt
• Imparting knowledge effects change on a larger scale.
Lessons learnt- leading & managing principles Changing work environment requires constant use of leading and managing principles.
Leading principles:
• Inspire and motivate relevant stakeholders to work towards common goals.
• Projects can be completed with commitment.
• Commitment versus Compliance
• TEAM - Together Everyone Achieves More
Managing principles
• Importance of Policy Implementation
• Monitoring and Evaluation
Way forward 1. Continue with PTC having STG/EML as standing item on the
agenda.
2. Monitor prescriptions on a daily basis for compliance to STGs across many diseases and present to management at clinical forums
3. Address deviations and non compliance with relevant prescribers and Medical Managers
4. Provide feedback to prescribers and pharmacists
5. Introduce STG/EML training as part of the annual orientation programme for new doctors and pharmacists
Inspiration……
The
journey of a
1000 miles
Begins
with a
single step…. Chinese philosopher-Lao-tzu
References
• National Drug Policy, 1996, National Department of Health
• Essential Medicines Lists- Hospital Level, 2006 and 2012
• Minutes of KZN PTC, 2010 to 2013
• Public Finance Management Act 1 of 1999
Acknowledgements
• KZN Pharmaceutical Services
• SIAPS/MSH /USAID (this work was presented previously at the final PLDP Presentation to USAID)
• Institutional Management and Pharmacy Staff at Stanger , Montebello, Sundumbili CHC
• Pharmacy Manager Sundumbili CHC
• Doctors and Pharmacists
• Our team members
The End Thank You Siyabonga Siyabulela